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Number Reading in Pure Alexiaâ Neuropsychologia 49 (2011) 2283–2298 Contents lists available at ScienceDirect Neuropsychologia jo urnal homepage: www.elsevier.com/locate/neuropsychologia Reviews and perspectives Number reading in pure alexia—A review a,∗ b Randi Starrfelt , Marlene Behrmann a Center for Visual Cognition, Department of Psychology, Copenhagen University, O. Farimagsgade 2A, DK-1353 Copenhagen K, Denmark b Department of Psychology, Carnegie Mellon University, Pittsburgh, PA, USA a r t i c l e i n f o a b s t r a c t Article history: It is commonly assumed that number reading can be intact in patients with pure alexia, and that this Received 25 October 2010 dissociation between letter/word recognition and number reading strongly constrains theories of visual Received in revised form 31 March 2011 word processing. A truly selective deficit in letter/word processing would strongly support the hypothesis Accepted 22 April 2011 that there is a specialized system or area dedicated to the processing of written words. To date, however, Available online 4 May 2011 there has not been a systematic review of studies investigating number reading in pure alexia and so the status of this assumed dissociation is unclear. We review the literature on pure alexia from 1892 to Keywords: 2010, and find no well-documented classical dissociation between intact number reading and impaired Pure alexia letter identification in a patient with pure alexia. A few studies report strong dissociations, with number Alexia without agraphia reading less impaired than letter reading, but when we apply rigorous statistical criteria to evaluate Letter-by-letter reading Visual recognition these dissociations, the difference in performance across domains is not statistically significant. There Number reading is a trend in many cases of pure alexia, however, for number reading to be less affected than letter Dissociation identification and word reading. We shed new light on this asymmetry by showing that, under conditions of brief exposure, normal participants are also better at identifying digits than letters. We suggest that the difference observed in some pure alexic patients may possibly reflect an amplification of this normal difference in the processing of letters and digits, and we relate this asymmetry to intrinsic differences between the two types of symbols. © 2011 Elsevier Ltd. Open access under CC BY-NC-ND license. Contents 1. Introduction . 2284 2. Literature review . 2284 2.1. Methods . 2284 2.2. Results . 2285 2.2.1. No dissociation . 2285 2.2.2. Possible dissociations . 2286 2.3. A new analysis of published data . 2288 2.4. Summary of results . 2289 3. Normal performance and visual similarity . 2289 3.1. Normal recognition of letters and digits . 2289 3.1.1. Methods. 2289 3.1.2. Results . 2290 3.2. Visual similarity for letters and digits. 2290 3.2.1. Methods. 2290 3.2.2. Results . 2291 4. Discussion . 2291 Acknowledgements . 2293 Appendix A.. 2293 References . 2297 ∗ Corresponding author. Tel.: +45 35324886. E-mail address: [email protected] (R. Starrfelt). 0028-3932 © 2011 Elsevier Ltd. Open access under CC BY-NC-ND license. doi:10.1016/j.neuropsychologia.2011.04.028 2284 R. Starrfelt, M. Behrmann / Neuropsychologia 49 (2011) 2283–2298 1. Introduction patient’s score on task I is markedly lower than on task II, but where performance is not compared to a control group; (ii) a strong disso- Pure alexia is an acquired disorder of reading that leaves writ- ciation, where “neither task is performed at a normal level, but task ing and other language skills unaffected (hence the term ‘pure’). I is performed very much better than task II” (p. 228). In this case, The disorder is characterized by slow and effortful but mostly cor- performance is commonly compared to a normal control group, rect reading, with a pronounced effect of word length on reading but a patient’s performance on tasks where normal controls would latency: Reaction times increase linearly with word length, often be expected to perform at ceiling may also constitute evidence with hundreds of milliseconds per letter. Pure alexia is associated for a strong dissociation (i.e., in the absence of directly compar- with a lesion impacting occipito-temporal areas of the left hemi- ing the patient to a control, one assumes perfect or near-perfect sphere, and damage to the left mid-fusiform gyrus, in particular, performance for normal individuals); and (iii) a classical dissocia- seems to play a causal role in this disorder (Leff, Spitsyna, Plant, tion, where – relative to normal controls – performance on task I & Wise, 2006). Other forms of acquired reading disorders, com- is impaired while performance on task II is within normal limits. monly termed central alexias, are seen following more widespread While trend dissociations are taken as a weak form of evidence, damage to temporo-parietal areas in the left hemisphere, and are both strong and classical dissociations have been interpreted as associated with more general deficits in language like aphasia and suggestive of specialized functions or modularity. Recently, more agraphia. A question that continues to plague theories of pure alexia refined (and operational) criteria specifying statistical demands for is whether the disorder is specific to alphabetic characters, and is dissociations have been suggested (e.g., Crawford & Garthwaite, caused by damage to or disconnection of a cerebral area dedicated 2005, 2007; Crawford, Garthwaite, & Grey, 2003). In brief, this to visual letter or word recognition (the so-called Visual Word Form approach demands that, in order to conclude that there is a classi- Area; Cohen et al., 2003, 2004; Gaillard et al., 2006), or whether it cal dissociation, the patient’s scores should differ significantly from emerges from a more general visuoperceptual deficit (Behrmann, the control group on one of two tasks, while performance should Nelson, & Sekuler, 1998; Farah & Wallace, 1991; Starrfelt, Habekost, be within the normal range on the other task, and – importantly & Leff, 2009). – the difference between the patient’s standardized scores in the One way to adjudicate between these alternatives is to examine two tasks should be significant. For the less stringent strong dissoci- the performance of pure alexic patients when presented with other ation, there should be a significant difference between the patient’s visual stimuli. It has often been suggested that number reading can standardized scores on the two tasks in question, while both scores be intact in patients with pure alexia (e.g.,Dehaene, 2009; Leff et al., may differ significantly from the mean of the control group. 2001), but, to date, there has not been a systematic review of the The presence of a clear classical dissociation would provide evidence regarding number reading in these patients. If number strong theoretical support for the independence or segregation of reading can remain intact following a lesion causing pure alexia, the system subserving processing of letters or words from the sys- this would offer convincing evidence of the specificity and selec- tem(s) subserving the visual processing of numbers. The absence tivity of the disorder, and would support the hypothesis that pure of a classical dissociation but evidence for a strong dissociation or alexia affects the processing of alphabetic material only. If, on the a trend dissociation would require further explication—numbers other hand, number reading is invariably impaired in patients with and letters/words might be mediated by separate systems, both pure alexia, this would suggest a more general (visual) deficit being of which are damaged albeit differentially, or the two domains at the core of the disorder. In this paper, we review the literature might potentially be subserved by the same system. If the latter on pure alexia from 1892 until 2010, and select for further inves- were true, an explanation that accounts for the differential impair- tigation all papers that describe a pure alexic patient’s reading of ment between the two domains will be required..
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